Introduction

The use of Peer Specialists (PS) by mental health service programs has grown considerably (Chinman et al., 2014; Shalaby & Agyapong, 2020). Although specific job titles and responsibilities of PS vary by program, these positions are frequently defined as being occupied by someone with personal experience of mental illness who draws on that experience to support others in their recovery. PS’ roles are diverse and may include leading individual support meetings, supporting group facilitation, mentoring clients, case management, and leading community outings (Ojeda, Jones, Munson, Berliant, & Gilmer, 2020). The use of PS is recognized by the United States Department of Health and Human Services as an evidenced-based mental health service model, and peer roles are widely accepted as a best practice by many mental health services programs, including those serving transition-age youth (TAY, youth ages 16–24) living with serious mental illness (SMI) (Mahlke, Krämer, Becker, & Bock, 2014; Simmons et al., 2020).

Compared to other adult populations, TAY have a relatively greater incidence of mental health challenges, in part due to the emergence of symptoms for many mental illnesses in early adulthood; historically, TAY have also been harder to engage and retain in mental health services than other adult groups (Bonnie, 2014; Cusick, Havlicek, & Courtney, 2012; Davis, 2003; Munson & McMillen, 2009; Vostanis, 2005). PS can play a critical role in the delivery of mental health and social support services for TAY with SMI and may help improve access to and continued engagement in mental health services by acting as a bridge between traditional service providers (e.g., therapists, psychiatrists, case managers) and TAY clients (Munson et al., 2021). Early engagement for the treatment of psychosis aims to reduce the duration of untreated illness, which is associated with improvements in clinical symptom severity and increases in rates of recovery (Hegelstad et al., 2012; Kane et al., 2016). A 2009 study of natural mentoring of youth transitioning out of foster care found that those with a mentor reported improved psychological outcomes (Munson & McMillen, 2009). More recently, an Australian qualitative study found that young adult peer workers (ages 17–21) believed that both their lived experience and youthfulness were critical to their ability to effectively support youth (Simmons et al., 2020). A recent study employing administrative mental health service utilization data in Southern California found that PS may also help to reduce racial health disparities by strengthening the engagement of minority TAY in mental health services (Ojeda et al., 2020).

Despite the growing use of PS within outpatient mental health service settings, less is known about how program managers train the peer workforce, support their work, and assist in their professional development (Ojeda et al., 2016; Ojeda et al., 2020). PS may benefit from diverse training strategies. For example, a 2020 national online survey of PS serving TAY found that 57% of respondents identified a training or skill need, including needing training to improve collaboration with other service providers, integrating technology in alignment with patient privacy policies and ethical principles, and meeting the specific needs of underserved populations including racial/ethnic minority TAY, and TAY with SMI and/or substance use disorders (SUD) (Jivanjee et al., 2020). Another large national survey of PS across the U.S. (N = 801) found that 60% reported having never had a single conversation with their supervisor about career development and advancement, and there were numerous other areas in which organizational support for career development was lacking (Jones, Teague, Wolf, & Rosen, 2020). Qualitative data from that study also detailed numerous perceived barriers to career development and advancement, including stigma and discrimination in the workplace and inadequate compensation (Jones, Kosyluk, Gius, Wolf, & Rosen, 2020). Importantly, a recent study which sampled both PS and their supervisors identified eight key factors for PS’ “on-the-job success”, including training, regular and individualized supervision, and skilled communication with colleagues (Delman & Klodnick, 2017).

This study reports qualitative findings from a sequential mixed-methods study investigating the role of peer support services in reducing disparities in the use of mental health care among TAY in two large, diverse California counties. This analysis draws on interviews with mental health program managers’ which sought their perspectives on strategies to support the professional development and capacity of PS. This study fills an important gap in the literature by addressing aspects of professional development needed to ensure PS’ success in the TAY-serving mental health services workforce.

Materials and Methods

Participants

We conducted a sequential mixed-methods study involving a quantitative survey in Phase 1 and qualitative interviews with program managers of publicly funded outpatient mental health programs in San Diego and Los Angeles Counties in Phase 2—these interviews are the focus of this analysis (Creswell & Hirose, 2019). Each county first provided the investigators with a list of county-funded mental health programs that serve TAY and in 2018-19, programs were queried to determine their use of PS (Ojeda et al., 2020). Next, we employed purposeful sampling to identify programs with 100 or more clients TAY clients, including Black and Latinx clients, and that also employed three or more paid peer providers; we identified eight unique programs to participate in qualitative interviews (n = 5 from Los Angeles County, n = 3 from San Diego County) (Palinkas et al., 2015). Between September and November 2019, program managers at these programs were contacted to participate in interviews and the principal investigator conducted interviews with 11 participants (n = 6 from Los Angeles County, n = 5 from San Diego County). Interviews ranged from 60 to 90 min and were digitally recorded.

Ethical Approval

Ethical approval for this study was granted and by the Human Subjects Research Protections Program of the University of California San Diego (Protocol #171,748), the Los Angeles County Department of Mental Health (Protocol #332), and the San Diego County Department of Behavioral Health Services (no Protocol # provided). Participants provided written informed consent for their data to be used in research.

Program Manager Interview Guide

The interview guide included semi-structured open-ended questions and probes that elicited program managers’ perspectives on peer specialist roles (see Tables 1 and 2), training needs (see Tables 3 and 4), and organizational strategies (see Tables 3 and 4) used to support PS professional development. Before initiating the interviews, the facilitator defined Peer Specialists’ services as “services that are provided by peers—individuals who have experienced with mental illness and assist others in their recovery.” TAY were also defined as youth and young adults between the ages of 16 and 24 but with the understanding that this definition may vary slightly across programs.

Table 1 Program managers’ descriptions of peer support specialists’ (PSS) characteristics
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Table 2 The role of peer support specialists (PSS) and the services they provide
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Table 3 Program managers’ support for peer support specialists’ (PSS) organization-facing responsibilities
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Table 4 Managers’ support for peer support specialists’ (PSS) client-facing responsibilities
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Data Management and Analysis

The investigators used MaxQDA 2020 software (VERBI Software, 20,219) to facilitate thematic analysis, as described below (Clarke & Braun, 2014; Maguire & Delahunt, 2017). First, interview audio files were transcribed verbatim by research assistants. Next, a coding scheme based on topics identified in the interview guide was developed and reviewed by the co-authors (CM, JLB, VO) for accuracy. The codes were applied to two transcripts by two co-authors (CM, JLB) who also used open coding was also used to identify emergent codes. Following the coders’ consensus, the coding scheme was finalized and applied to two new transcripts by both coders to assess inter-rater reliability. After resolution of coding conflicts and minor revisions to the coding scheme, satisfactory inter-rater reliability was achieved (i.e., 70%). The final code list was applied to the remaining transcripts by a single coder (Landis & Koch, 1977; O’Connor & Joffe, 2020; Roberts, Dowell, & Nie, 2019). Coded text segments across all interviews were collated into code reports and the co-authors (CM, JLB) summarized the code reports while assessing for similarities or differences in content and illustrative quotes were selected for inclusion in thematic data tables. To contextualize how programs support PS in their service delivery and professional development, we first describe how program managers perceive the peer role and characteristics of those successful in this position followed by program managers’ strategies to support PS who serve TAY clients.

Results

Characteristics of Peer Specialists

Program managers were asked to characterize the Peer Specialist role (PS) and how these staff are unique from other staff members (see Table 1, Theme 1, subthemes 1a, 1b, 1c). The emergent theme revealed that connections to TAY clients are built on PS’ lived experience and having an authentic, non-judgmental personality. Managers consistently identified lived experience with mental health disorders (e.g., personal experience, or with a family member or other close contact) as a job requirement. Managers felt that those who excel in the PS role are authentic, friendly, and empathetic– traits that were perceived to be related to their lived experience. Managers conveyed that their PS colleagues often displayed a passion for service and have strong communication skills which enable them to share their experiences in an empathetic, genuine, non-judgmental way. Finally, managers characterized their PS as friendly and approachable; they felt these traits help clients feel welcome and support service use.

Managers were asked to identify any characteristics for which matching between PS and their TAY clients was important (see Table 1, Theme 2, subthemes 2a, 2b). The data suggest that compatibility in demographic traits and shared interests can help the PS-client relationship. For example, several managers noted that having PS that are similar in age to TAY clients seems to help the PS relate to clients due to a shared culture of youthfulness. Similarly, managers identified mutual interests (e.g., music, photography, sports, art) as a means for peers and clients to build a rapport. Managers’ responses varied regarding the importance of matching based on race/ethnicity. Several noted that racial/ethnic or linguistic concordance (e.g., fluency in/ability to speak Spanish) can support TAY clients’ engagement in services; this could be achieved by hiring peers who share characteristics of racial/ethnic subgroups.

Managers were asked to describe ways in which the PS role compared to that of other mental health service providers (see Tables 1, Theme 3, subthemes 3a, 3b). Our analysis indicated that PS have a unique, organic relationship with clients due to the flexible nature of the PS role. For example, several managers stated that PS engage with clients in diverse settings, including on-site as well as in the community, including in clients’ homes; in contrast, psychiatrists’, therapists’, and other staff members’ interactions with clients were typically limited to programmatic settings. Managers also frequently characterized PS’ work as flexible and less structured than that of other staff: for example PS are more likely to have informal meetings vs. structured sessions with clients. The relationship between PS and clients was also described as “more organic” and it may evolve over time due to clients’ changing needs. In contrast, non-PS staff may go “by the book”, adhering to their professional boundaries as outlined by their discipline’s best practices.

Functions of Peer Specialists

Table 2 presents managers’ descriptions of the PS role, which is expansive and inclusive of all stages of service utilization. Managers reported that PS often conduct outreach to engage TAY in mental health services (see Table 2, Theme 1, Subthemes 1a, 1b). For example, PS might attend health fairs, host educational activities in the community or conduct mental health screenings at schools. PS were described as effective and instrumental in connecting underserved clients (e.g., clients unfamiliar with or intimidated by mental health care, unsheltered youth) to mental health services, often for the first time, or supporting their continued engagement with mental health as well as other services. Managers felt that PS’ disclosure of their lived experience helps build rapport and trust with clients and enables PS to address TAY clients’ concerns, translate mental health jargon into lay language, and create a welcoming environment in mental health program venues. From managers’ perspectives, PS tend to use their lived experience to model recovery for clients and increase clients’ comfort with utilizing mental health services. PS are also important in helping address TAY clients’ basic needs (see Table 2, Subthemes 2a, 2b, 2c). Notably, across all organizations, managers explained that PS must be flexible and adaptable, performing tasks across numerous domains to meet clients’ diverse needs including securing or providing transportation or housing, and facilitating linkages to medical care, modeling and practicing independent living skills (e.g., use of public transportation, shopping, hygiene, housekeeping, budgeting), and leading groups and or other activities (e.g., music/art events) in support of the recovery process.

Program Support for Peers’ Organization-Facing Responsibilities

Program managers described ways in which their programs support PS to carry out their administrative responsibilities (see Table 3). Managers frequently discussed the importance of documentation by PS, both in the service of clients’ care and for continued financing of services (see Table 3, Theme 1). However, they also identified challenges PS and other staff may have with documentation, including determining what information to record or carving out the time to fully document their work. In response, many managers described leading discussions regarding the critical role that documentation plays in maintaining quality care. Managers also sought out or provided documentation-focused technical trainings (e.g., what to document, how to prepare notes in order to meet reimbursement standards). Some managers carried out ongoing check-ins with PS and provided regular feedback on record-keeping. Programs also addressed time management challenges as they pertained to balancing documentation and client services. Thus, several programs hosted “admin parties” where PS could catch up on paperwork together and receive help from their supervisors if needed. PS received mentorship on time management, particularly as it pertained to conducting client services out in the field; one program required notes to be prepared within a pre-determined period (e.g., 5 days) and PS received devices (e.g., cell-enabled tablet computers) to support documentation while in the field and the information was fresh.

Managers reported supporting PS as equal and valued team members (see Table 3, Theme 2). Specifically, some made a conscientious effort to ensure that PS were present at programmatic and client-care meetings; this was identified as a potential challenge given PS varied schedules as well as service delivery model which resulted in PS engaging with clients in the community. Some managers sought to create non-hierarchical teams which valued and respected all team members’ insights as these could support PS’ participation in team discussions for the benefit of client care; this was identified as a need given that health care is often hierarchical. Some managers felt that supporting enhanced communication between PS and other staff members could lead to a greater understanding of PS’ contribution to client engagement in services and the recovery process. Other methods to involve PS included having PS host team building exercises and lead staff meetings. One manager also suggested that holding trainings to explain the duties and roles of the different team members, including the unique role of PS, would benefit all staff members. Finally, managers also identified a need to support the professional development of PS by helping them navigate difficult conversations, work-place disagreements, and determining the sharing of personal information for the benefit of the client.

Program Support for Peers’ Client-Facing Responsibilities

Table 4 presents managers’ descriptions of how programs support PS across diverse areas to support client-facing work. Managers felt that certain mental health trainings were essential for preparing PS to ensure client safety and well-being (e.g., Wellness Recovery Action Plan [WRAP], trauma-informed care, Seeking Safety, identifying and responding to suicidal ideation) (see Table 4, Subtheme 1a). Cultural competency training was important for serving diverse racial/ethnic groups and sexual and gender minority communities; importantly, these trainings were often provided by community partner agencies with expertise in sexual and gender minority needs and services (see Table 4, Subtheme 1b, Theme 2, Subtheme 2a). Additionally, programs often formed partnerships with lesbian, gay, bisexual, transgender, and queer (LGBTQ)-focused organizations with the goal of ensuring that PS and other staff were aware of the range of resources available from community partners. Managers reported that these collaborations and greater agency awareness of LGBTQ issues also benefitted the program more broadly by helping create a physically welcoming space for LGBTQ TAY. Additionally, managers reported that training PS on self-disclosure and how to use their experiences in supporting clients is especially helpful when PS are early in their careers. For example, several managers noted that some PS struggled with oversharing, inappropriate sharing, or sharing in ways that overly centered their own lived experience and training and supervision could help address these concerns (see Table 4, Subtheme 1c). Additionally, some programs implemented trainings on self-disclosure that sought to ensure that peers shared relevant aspects of their lived experience in a manner that was both personally comfortable as well as effective for the client.

Due to PS’ fluid client-serving roles, managers reported that PS benefit from two types of supervision—individual and group-based (see Table 4, Subthemes 3a and 3b). Individual supervision activities, including open-door supervision whereby PS had unrestricted access to program managers, aim to provide PS with immediate feedback and support regarding client care or productivity. In contrast, group-based supervision allowed for a collaborative approach to problem solving and capacity building while also enabling PS to discuss shared concerns and for supervisors to adjust and redistribute caseloads as needed. PS received supervision and support from administrative staff and clinical staff (e.g., therapists), and in some cases, more senior and experienced PS who were able to provide mentorship to their colleagues.

Discussion

This study characterizes how program managers of outpatient mental health clinics serving TAY in Southern California conceive of peer work and how their programs support PS as they interface with clients and colleagues as they carry out their professional duties. Managers reported that PS’ client-focused and administrative responsibilities are multifaceted and wide-ranging and may require unique skill sets. For example, PS may provide emotional support, facilitate group activities, conduct outreach and field-based services, collaborate on treatment teams, and undertake administrative tasks such as documentation of services provided. These findings are consistent with existing research which shows that peers’ responsibilities vary greatly both within and between organizations (Blash, Chan, & Chapman, 2015; Chapman, Blash, Mayer, & Spetz, 2018; Cronise, Teixeira, Rogers, & Harrington, 2016; Jones, Teague, et al., 2020; Ojeda et al., 2020; Salzer, Schwenk, & Brusilovskiy, 2010).

Several managers identified flexibility as an important characteristic of successful PS, particularly because clients’ needs may differ over time and may vary across clients. However, role ambiguity may be experienced by the PS or their colleagues. Thus, a greater breadth and depth of supervision, support and training may be needed to ensure that PS have the resources needed to be successful. This study identified diverse supervision strategies and trainings as a means of addressing professional development and workplace challenges, including building PS technical and administrative skills (e.g., time management), disclosure, and interpersonal relationships (Baggetta & Alexander, 2016). These efforts may build PS’ skills in support of their professional development and long-term career trajectories (Delman & Klodnick, 2017).

Managers also reported that PS’ supervisors can serve as a bridge between PS and program staff, helping to foster team members’ understanding of the PS role and facilitating the integration of peers into teams and team activities (e.g., meetings). These strategies are in alignment with recommendations provided by the “National Practice Guidelines for Peer Specialists and Supervisors,” which suggests that mutual respect with clearly defined boundaries, coaching, and ongoing reciprocal dialogue and collaboration throughout supervision activities are among the strategies that supervisors can employ in support of PS (National Association of Peer Supporters, 2019).

Stefancic and colleagues found that having supervisors and PS engage in ongoing discussions regarding PS roles and responsibilities can foster a mutual understanding of the program structure, services, and client goals while also reducing PS’ stressors tied to role ambiguity (Stefancic et al., 2021). Furthermore, ensuring that PS have a space and mechanism to provide the program and team members with feedback is important to PS’ feeling valued and treated as equal partners (Stefancic et al., 2021). Kuhn and colleagues found that job satisfaction was greater among PS when they felt their supervisors had a deeper understanding of their role (Kuhn, Bellinger, Stevens-Manser, & Kaufman, 2015). Taken together, these findings suggest that supervisors likely need to implement multiple strategies in order to foster trust, respect and understanding of PS’ roles and their contributions to the program among all staff members and the critical role that PS play in TAY clients’ recovery process; such efforts may help create more cohesive teams and benefit client care and this should be evaluated more fully.

Prior studies have documented the emotional labor associated with peer work and its impact on PS’ mental health (Mancini & Lawson, 2009; Moran, Russinova, Gidugu, & Gagne, 2013). Our study found that programs implement both structured and unstructured opportunities for PS to receive support and supervision. An open-door policy can facilitate peers’ ongoing access to supervisors or colleagues to address self-care and the development of coping skills to manage diverse client-related or work-place related stressors. Such approaches may help foster persistence and resilience to work in challenging situations as well as confidence to carry out the PS role (Delman & Klodnick, 2017) and potentially may reduce feelings of burnout as evidenced among PS with lower levels of self-efficacy (Park, Chang, Mueller, Resnick, & Eisen, 2016).

Prior studies have found that PS may need additional support to address cultural dimensions of client care (Delman & Klodnick, 2017). Nationally, there are concerted efforts designed to support inclusivity with the goal of reducing disparities in service utilization and engagement among racial/ethnic subgroups and sexual and gender minorities (SGM) (National Institutes of Health: National Institute on Minority Health and Health Disparities, 2021; National Institutes of Health: Sexual and Gender Minority Research Office, 2021). This study found that programs serving TAY living with serious mental illness sought to address cultural dimensions of care by engaging PS from diverse racial/ethnic and linguistic subgroups that are reflective of the community they serve. Additionally, program managers were mindful of the need to engage in ongoing cultural competency trainings, particularly to foster inclusivity of SGM TAY. For example, programs developed or strengthened collaborations with community agencies with expertise in SGM well-being and services to build PS and other staff members’ knowledge of current terminology. Programs also actively sought to demonstrate the agency’s allyship with the SGM community through creating welcoming programmatic spaces and developing events for SGM TAY. Broader assessment of these approaches is needed to understand how these efforts contribute to SGM TAYs’ uptake of services.

Limitations

This study focused on providing an organizational perspective on PS training and supervision; PS perspectives were also collected as part of the larger study and findings of that analysis will be published separately due to the expansiveness of the data. Our study relied on semi-structured interviews with program managers which may be impacted by recall bias. The study did not implement member checking strategies and this may be a valuable approach to use in future studies to ensure comprehensiveness of the data and that interpretation of interviews was consistent with the participants’ intent. Due to the onset of the COVID-19 pandemic during data analysis, engagement of participants would have been difficult to California’s strict policies which led to a long-term implementation of remote work and quarantine period. The study did not collect the demographic data of supervisors and this should be included in future studies; such data may facilitate exploration of racial/ethnic concordance of PS and supervisors in settings serving TAY. The study was conducted in two large urban communities in Southern California which may limit generalizability of findings; future studies should expand to other contexts (e.g., rural or suburban communities). Interviews were conducted immediately prior to the COVID-19 pandemic and the approaches described here may have been subsequently adapted to address emergent public health directives; further research is needed to ascertain how the pandemic impacted organizational support of PS as well as service delivery for TAY clients. California lacked standardized guidelines for PS at the time of the study, likely resulting in greater variation of the PS role and supervision activities, however, that is expected to change with finalization of the peer certification law which will be in effect in 2022 (California Department of Health Care Services, 2021). The study did not collect data on whether the supervisors believed they needed further training to better support Peer Specialists—these factors should also be explored in a further study.

Conclusions

This study provides a recent view of program managers’ perspectives on the role of PS within mental health service programs that serve TAY living with serious mental illness. Findings demonstrate that program managers appreciate and understand the value of peer support within mental health services that seek to engage diverse TAY clients, as well as the complexity of the PS role. Consequently, managers responded with varied strategies to support PS so that they may be personally and professionally successful. Results from this study may inform the field on how to improve the implementation and sustainment of high-quality peer support, while also providing insight regarding the long-term development of PS and protocols to support them and their careers; these are neglected areas of focus. Longitudinal research is needed to assess the impact of such organizational efforts on PS’ job satisfaction and productivity, career trajectories, as well as TAY clients’ engagement with services, particularly among racial/ethnic minority and sexual and gender minority TAY clients.